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Diagnostic Procedures and Clinical Management
©@~~lliJ~O©&ifO@~® TO THe eDITOR
ment of these neoplasms, but he can decide whether it is likely to make the diagnosis. Norman H . Solliday, M.D. , F.C.C.P. Assistant Professor of Medicine JVorthwestem University Medical School Chicago
Diagnostic Procedures and Clinical Management To the Editor: In a well-reasoned editorial on techniques of bronchoscopic biopsy in the June 1976 issue (Chest 69:7107ll, 1976), Solliday concluded that "innovations be critically evaluated under actual patient-care situations in regard to hard end points, such as success or failure of diagnosi:l" (italics mine). I believe that considering "success or failure of diagnosis" as the ultimate means in evaluating the procedure misses what medicine is all about. The physician wants to know "what procedure will alter my management of the patient's problem ... The patient with good pulmonary function whose biopsy or brushing is diagnostic for epidermoid or adenocarcinomatous neoplasia will go to mediastinoscopy and thoracotomy. So will he if the biopsy and brushing are inconclusive. The value of a technique for biopsy is best determined by evaluating how many patients are saved from thoracotomy or other procedures because of the biopsy. Thus, I strongly urge that meaningful comparisons of diagnostic techniques deal with our ability to diagnose oat cell carcinoma, granulomatous disease, and other benign conditions, the diagnosis of which saves patients more hazardous and discomforting surgical procedures. Y. Aelony, M.D. Division of Pulmonary Diseases Southern California Permanente Medical Group Harbor City, Calif
To the Editor: I agree with Aelony that ultimately the value of a diagnostic procedure will be decided on how the procedure affects management of clinical problems. Nevertheless, it is frequently useful to restrict our scrutiny to narrower questions that can be more precisely defined. Proper management is a complex mixture of factual and judgmental issues, to which proper diagnosis is only one conbibutor. If management of a problem is controversial, then the question of whether a procedure conbibutes to management may be indeterminate when a simpler question, such as whether the procedure is likely to be diagnostic, is answerable. An example may be found in the communication by Aelony. Apparently, he would proceed to mediastinotomy after a diagnosis of either epidermoid or adenocarcinoma had been made by bronchoscopy. Other physicians1 would do mediastinoscopy only in the latter disease. Given this conflict, the clinician may be unable to decide whether bronchoscopy conbibutes to manage-
718 COMMUNICAnONS TO THE EDITOR
REFERENCE
1 Whitcomb ME, Barham E, Goldman AL, et al: Indications for mediastinoscopy in bronchogenic carcinoma. Am Rev Respir Dis 113: 189-195, 1976
Pneumothorax Associated with Bronchogenic Carcinoma To the Editor: We read with interest the report by .Mahajan and associates1 of a patient with giant cell carcinoma of the lung presenting as pneumothorax. We have recently studied a similar case. CASE REPoRT
A 31-year-old white man was seen in the emergency room of Ochsner Foundation Hospital because of the sudden onset of pain in the right lower portion of the chest, accompanied by shortness of breath. The patient had smoked five packs of cigarettes daily for the preceding three years. Decreased breath sounds and hyperresonance were present over the right hemithorax. Achest x-ray film revealed a right pneumothorax with no mediastinal shift. A closed-tube thoracotomy was performed, with satisfactory ree.xpansion of the lung. The tube was removed after four days, and chest x-ray films revealed satisfactory reexpansion of the lung. The patient returned one week later with recurrence of the right-sided chest pain and dyspnea. A chest x-ray film again revealed a right pneumothorax, with a slight leftward shift of the mediastinum. A closed-tube thoracotomy again satisfactorily reexpanded the right lung. At this time, cytologic study of the pleural fluid yielded negative findings for malignant disease. At bronchoscopic examination, thick mucoid secretions were present in the right mainstem bronchus, but no lesion was found. The chest tube was removed after nine days, but a small pneumothorax remained on the right side, near the apex. Following the patient's discharge from the hospital, chest x-ray films at two-week intervals showed no change in the right hemithomx; however, six weeks after discharge, the patient again reported dyspnea at rest, and a chest x-ray film revealed an increase in the pneumothorax. The patient was readmitted. Bronchoscopic examination was performed, but again no lesion was found. Because of the suspicion of a bronchopleural fistula, a right thoracotomy was done. At surgery, a bulla with surrounding induration was present at the apex of the lung. Frozen sections revealed an undifferentiated carcinoma, and a lobectomy of the right upper lobe was performed. Microscopic sections of the tumor revealed a highly undifferentiated carcinoma growing through and, in some places, destroying the pleura. Following discharge from the hospital, the patient did
CHEST, 70: 6, DECEMBER, 1976
ment of these neoplasms, but he can decide whether it is likely to make the diagnosis. Norman H . Solliday, M.D. , F.C.C.P. Assistant Professor of Medicine JVorthwestem University Medical School Chicago
Diagnostic Procedures and Clinical Management To the Editor: In a well-reasoned editorial on techniques of bronchoscopic biopsy in the June 1976 issue (Chest 69:7107ll, 1976), Solliday concluded that "innovations be critically evaluated under actual patient-care situations in regard to hard end points, such as success or failure of diagnosi:l" (italics mine). I believe that considering "success or failure of diagnosis" as the ultimate means in evaluating the procedure misses what medicine is all about. The physician wants to know "what procedure will alter my management of the patient's problem ... The patient with good pulmonary function whose biopsy or brushing is diagnostic for epidermoid or adenocarcinomatous neoplasia will go to mediastinoscopy and thoracotomy. So will he if the biopsy and brushing are inconclusive. The value of a technique for biopsy is best determined by evaluating how many patients are saved from thoracotomy or other procedures because of the biopsy. Thus, I strongly urge that meaningful comparisons of diagnostic techniques deal with our ability to diagnose oat cell carcinoma, granulomatous disease, and other benign conditions, the diagnosis of which saves patients more hazardous and discomforting surgical procedures. Y. Aelony, M.D. Division of Pulmonary Diseases Southern California Permanente Medical Group Harbor City, Calif
To the Editor: I agree with Aelony that ultimately the value of a diagnostic procedure will be decided on how the procedure affects management of clinical problems. Nevertheless, it is frequently useful to restrict our scrutiny to narrower questions that can be more precisely defined. Proper management is a complex mixture of factual and judgmental issues, to which proper diagnosis is only one conbibutor. If management of a problem is controversial, then the question of whether a procedure conbibutes to management may be indeterminate when a simpler question, such as whether the procedure is likely to be diagnostic, is answerable. An example may be found in the communication by Aelony. Apparently, he would proceed to mediastinotomy after a diagnosis of either epidermoid or adenocarcinoma had been made by bronchoscopy. Other physicians1 would do mediastinoscopy only in the latter disease. Given this conflict, the clinician may be unable to decide whether bronchoscopy conbibutes to manage-
718 COMMUNICAnONS TO THE EDITOR
REFERENCE
1 Whitcomb ME, Barham E, Goldman AL, et al: Indications for mediastinoscopy in bronchogenic carcinoma. Am Rev Respir Dis 113: 189-195, 1976
Pneumothorax Associated with Bronchogenic Carcinoma To the Editor: We read with interest the report by .Mahajan and associates1 of a patient with giant cell carcinoma of the lung presenting as pneumothorax. We have recently studied a similar case. CASE REPoRT
A 31-year-old white man was seen in the emergency room of Ochsner Foundation Hospital because of the sudden onset of pain in the right lower portion of the chest, accompanied by shortness of breath. The patient had smoked five packs of cigarettes daily for the preceding three years. Decreased breath sounds and hyperresonance were present over the right hemithorax. Achest x-ray film revealed a right pneumothorax with no mediastinal shift. A closed-tube thoracotomy was performed, with satisfactory ree.xpansion of the lung. The tube was removed after four days, and chest x-ray films revealed satisfactory reexpansion of the lung. The patient returned one week later with recurrence of the right-sided chest pain and dyspnea. A chest x-ray film again revealed a right pneumothorax, with a slight leftward shift of the mediastinum. A closed-tube thoracotomy again satisfactorily reexpanded the right lung. At this time, cytologic study of the pleural fluid yielded negative findings for malignant disease. At bronchoscopic examination, thick mucoid secretions were present in the right mainstem bronchus, but no lesion was found. The chest tube was removed after nine days, but a small pneumothorax remained on the right side, near the apex. Following the patient's discharge from the hospital, chest x-ray films at two-week intervals showed no change in the right hemithomx; however, six weeks after discharge, the patient again reported dyspnea at rest, and a chest x-ray film revealed an increase in the pneumothorax. The patient was readmitted. Bronchoscopic examination was performed, but again no lesion was found. Because of the suspicion of a bronchopleural fistula, a right thoracotomy was done. At surgery, a bulla with surrounding induration was present at the apex of the lung. Frozen sections revealed an undifferentiated carcinoma, and a lobectomy of the right upper lobe was performed. Microscopic sections of the tumor revealed a highly undifferentiated carcinoma growing through and, in some places, destroying the pleura. Following discharge from the hospital, the patient did
CHEST, 70: 6, DECEMBER, 1976